Provider Demographics
NPI:1124396775
Name:KEITH A. BRADY M.D., P.A.
Entity Type:Organization
Organization Name:KEITH A. BRADY M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:JEANETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:FLORES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-820-7992
Mailing Address - Street 1:1099 5TH AVE N
Mailing Address - Street 2:150
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-1469
Mailing Address - Country:US
Mailing Address - Phone:727-820-7900
Mailing Address - Fax:727-820-7901
Practice Address - Street 1:1099 5TH AVE N
Practice Address - Street 2:150
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1469
Practice Address - Country:US
Practice Address - Phone:727-820-7900
Practice Address - Fax:727-820-7901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME37799207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL62426BMedicare PIN